It behooves physicians to are at significant risk of anaphylaxis leading to rapid question their patients regarding these products generic 200mg vantin mastercard antibiotics for uti starting with m, espe- bronchial constriction generic vantin 100 mg on-line virus 32 removal, laryngeal edema, hypotension, cially when prescribing 3 or 4 g/d for arthritis, and, often, death. Another important precaution because many patients are taking products that they regarding aspirin is that it should never be given to do not realize contain acetaminophen. The result can children under the age of 2 years who are suffering be inadvertent overdose and toxicity. Intentional or accidental overdoses of 20% among those who are sensitive to aspirin. In acetaminophen are common, and every emergency patients with Franklin’s triad, cross-reactivity is room has protocols in place to treat these potentially extremely high (approximately 85%). For example, celecoxib NSAID STARTING DOSE is contraindicated in patients with allergy to sulfa Celecoxib (Celebrex) 100 mg qd drugs. In this situation, a rash should not preclude the Choline magnesium salicylate (Trilisate) 750 mg bid choice of another NSAID. Piroxicam (Feldene) and Diclofenac sodium (Voltaren) 50 mg bid Diclofenac potassium: immediate release 50 mg tid sulindac (Clinoril) are two agents where macular pop- Diflunisal (Dolobid) 500 mg bid ular rashes are reasonably common. When the offend- Etodolac (Lodine) 400 mg bid ing agent is stopped, the rash goes away and another Fenoprofen (Nalfon) 200 mg qid can be chosen. Ibuprofen (Motrin, Advil, Nuprin) 200 mg qid Indomethacin (Indocin) 25 mg bid While aspirin is recognized primarily as preventive Ketorolac (Toradol) 10 mg bid therapy for heart attacks and strokes, a 6-year ran- Ketoprofen tromethamine (Orudis, Oruvail) 75 mg bid domized trial conducted among 5139 apparently Meclofenamate (Meclofen) 50 mg tid healthy male doctors found that those taking 500 mg Mefenamic acid (Ponstel) 250 mg qd Meloxicam (Mobic) 7. Quantification tables exist for the relative inhibition of COX-1/COX-2 by various NSAIDs, NSAIDs are an important component in balanced but introduction of the relatively selective agents analgesia in the management of acute and chronic (celecoxib, rofecoxib, and valdecoxib), more com- pain. Table 10–1, and the elimination half-lives in Table Etodolac (Lodine), nabumetone (Relafen), and 10–2. Franklin’s triad (syndrome of nasal polyps, Although NSAIDs act primarily through their effects angioedema, and urticaria) in whom anaphylactoid on peripheral prostaglandin synthetase, additional reactions have occurred. Ibuprofen 1–2 The two isoforms of cyclooxygenase, COX-1 and Ketoprofen 2 COX-2, are genetically distinct, with COX-1 located Ketorolac 4–6 on chromosome 7 and COX-2 on chromosome 1. Nabumetone (6NMA) 24 Naproxen 14 COX-1 is considered constitutive or part of the basic Oxaprozin 40 constitutional homeostasis, while COX-2 is inducible; Rofecoxib 17 that is, it responds to specific insult. Tolmetin 5 Valdecoxib 8–11 The goal is to inhibit COX-2 while preserving 48 IV ANALGESIC PHARMACOLOGY central mechanisms for their action have also been effective in low back pain syndromes. Combining an optimal PAIN dose of an NSAID with an opioid produces an addi- tive analgesic effect known as synergy that is greater In the American Pain Society’s March 2002 guide- than that obtained alone by doubling the dose of either lines for the management of pain in osteoarthritis, drug. Hence, drug displace- ciated with osteoarthritis and a selective COX-2 ment occurs when NSAIDs are combined with other inhibitor for moderate to severe pain and inflamma- highly protein-bound drugs, including warfarin tion. Data gathered during the 1-year “VIGOR” to platelet cyclooxygenase is reversible. Thus, coagu- study of this comparison showed that rofecoxib was lation is affected by aspirin as long as that platelet is associated both with a significantly lower incidence alive and circulating, approximately 3 weeks. If a of serious upper gastrointestinal events and with a sig- patient is on daily aspirin and is scheduled for major nificantly higher incidence of serious cardiovascular surgery, especially cardiovascular surgery, it is pru- events. Various authors have suggested that this effect dent to substitute a shorter-acting NSAID with an is likely due to naproxen’s ability to inhibit platelet equally short effect on coagulation, such as ibuprofen aggregation; rofecoxib does not have this effect. Rofecoxib for pain at the 50-mg/d dose has not been Only ketorolac is available in both oral and parenteral studied for more than 5 days and, hence, is not rec- formulations. These include diclofenac sodium (Voltaren), naprosyn STRUCTURE AND FUNCTION sodium (Anaprox), and ketorolac (Toradol). Some clinicians have advocated try- cept (Enbrel), infliximab (Remicade, Centocor), ing an agent from another class if the first choice does leflunomide (Arava), mycophenolate mofetil (Cell not work. Although this view has not been well sup- Cept), and cyclosporin (Neoral). Acetaminophen is a ported, switching classes may be of value in patients para-aminophenol derivative with analgesic and who experience problematic side effects. Colchicine is not an analgesic and is gener- tle differences in pharmacodynamics.

Given the absence of muscles on the anterior and Occurrence superior sections cheap 100mg vantin amex do topical antibiotics for acne work, the shape and length of the clavicles Apart from the spina scapulae vantin 200 mg visa antibiotic kidney failure, the acromion and the substantially determine the appearance of the shoulder coracoid, the scapula is deeply embedded on all sides in girdle. As a spacer between the acromion and sternum, it the protecting musculature. Scapular fractures are very rare and evidence of monest injury caused by birth trauma. In terms of prognosis, the latter The clavicle plays a key role in the functional are more decisive than the scapular fracture. Diagnosis Diagnosis Clinical features Clinical findings The clinical picture is dominated by the additional in- In children and adolescents the local pain over the clavicle juries to the skull, thorax and abdomen. Although rarely associated with finding locally is a painful restriction of movement of a clavicular fracture, a plexus palsy should be ruled out the shoulder, particularly from 70–90° of glenohumeral. The latter can also be induced by an excessively tight abduction, when the scapula starts to rotate as well. Imaging investigations Imaging investigations The conventional radiological presentation of a scapular AP x-ray of the clavicle. In view of the superficial position fracture on AP and Y views is occasionally inconclusive. Otherwise the absence of symptoms is evidence account for the highest proportion, by far, of all clavicular of consolidation. The younger the child, the more likely it is that the fracture will be non-displaced. Surgical Lateral fractures frequently correspond to epiphyseal Open reduction and internal fixation of shaft fractures is separations and, in clinical respects, resemble an acro- indicated only in exceptional cases: mioclavicular dislocation as seen in over 13-year olds or Shortening in excess of 2 cm after physeal closure. The risk of pseudarthrosis is higher during childhood and the cosmetic result is often experienced to be! In this case, the patient should be inferior section of the periosteal sleeve and the informed, preoperatively, particularly about the wide, adjacent coracoclavicular ligaments remain in- keloid-like scars that can often result. The outstanding osteogenic potential of the ▬ Open fractures or fractures with threatened penetra- periosteum leads to rapid consolidation and im- tion. Medial fractures are rare and represent epiphyseal separa- Pathological fractures. We prefer internal fixation with a small-fragment plate Treatment fixed to the clavicle from the bottom. Conservative Medial epiphyseal separations with retrosternal dislo- cation require emergency reduction, usually as an open! Displaced fractures with an ad latus deformity and short- All that is required for treating the pain, therefore, is ening result in a distinct bony bulge, which is often even immobilization in a simple arm sling for 2 weeks in com- more accentuated at a later stage as a result of marked bination with oral analgesics for 3–4 days. Both the bulging and the shortening after a figure-of-eight strap and an arm sling are identi- remodel themselves if the growth plates are still open, cal. Depending on the severity of the symptoms, arm- although this takes from 6–12 months. Informing the par- hanging exercises may be initiated independently after ents and the patient accordingly will prevent additional just 1–2 weeks. For initially displaced fractures, an x-ray consultations and unnecessary corrective procedures. Apart from the few cases resulting from birth trauma, these fractures occur mainly in over 10-year olds. A conservative approach with early functional mal humeral epiphyseal plate, which appears roof-shaped therapy is particularly suitable for fractures of the from the front and flat from the side. However, such differences are of no Diagnosis therapeutic importance, and very rarely of any prog- Clinical features nostic significance, since relevant growth disturbances Pain in the area of the proximal humerus. The hyperextension traumata lead to tilting in the Imaging investigations dorsal direction, but rarely to instability. Depending on the forced posture Epiphyseal fractures (Salter types III and IV) and avulsion produced by the pain, the proximal humerus may not ap- fractures of the lesser tubercle are rare, as are subcapital pear to be affected from the front on the AP view or from fractures in combination with glenohumeral dislocation a strictly lateral position on the Y view. Ad latus deformities by the full shaft width and shortening of up to 2 cm.

Mehlmann CT discount vantin 100mg visa antibiotics gut microbiome, Hubbard GW buy discount vantin 100mg line infection of the heart, Crawford AH, Roy DR, Wall EJ (2000) ments, but is essential at the end of surgical fixation. Morsy HA (2001) Complications of fracture of the neck of the ▬ Restricted mobility: femur in children. Injury 32: 45–51 – After Prévot nailing: Usually caused by an irritating 11. Ogden JA (1974) Changing patterns of proximal femoral vascular- nail end at the medial femoral epicondyle beneath ity. Raney EM, Ogden JA, Grogan DP (1993) Premature greater tro- – After external fixation: Can largely be avoided by a) chanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop 13: 516–20 flexing the knee to its maximum extent at operation 13. Silber JS, Flynn JM (2001) Role of computed tomography in the to facilitate the passage of the pins through the fas- classification and management of pediatric pelvic fractures. J cia lata, and b) positioning the knee intermittently Pediatr Orthop 21:148–51 in 90° hip and knee flexion for several days postop- 14. Silber JS, Flynn JM (2002) Changing patterns of pediatric pelvic eratively (using a foam block). Pierre P, Staheli LT, Smith JB, Green NE (1995) Femoral neck Pin-track infections can be expected to occur in pa- stress fractures in children and adolescents. J Pediatr Orthop 15: tients with external fixation in 5%–10% of cases, 470–3 even with a good standard of care/instruction. Trueta J (1957) The normal vascular anatomy of the human femo- seropurulent secretion and reddening at the pin in- ral head during growth. Oral broad- 7: 615–24 spectrum antibiotics, daily baths or showers and local 18. Weinberg AM, Hasler CC, Leitner A, Lampert C, Laer L (2000) Ex- pin care usually reduce the inflammation promptly. Treatment and Only in rare cases does the skin incision need to be results of 121 fractures. The frequency peaks around the age > Definition of 5 or 6, but it can also affect children at any age be- Transient synovitis is a hip joint effusion that occurs in tween 1 and 12/13. The annual risk of transient small children in connection with other illnesses (e. Transient synovitis is a symptom rather than the children affected subsequently experienced a second a separate illness. Another study in Ger- ▬ Synonym: Toxic synovitis many calculated an annual incidence of approx. A recurrence risk of 15% was determined in a Brit- Etiology ish study. Since transient synovitis occurs as a symptom in asso- ciation with other, usually viral, infections, there is no Clinical features, diagnosis uniform etiology [1, 16, 24]. It involves a reaction to a The joint effusion causes pain, which manifests itself as process outside the hip, most commonly a viral in- limping and restricted hip movement. Depending on the fection of the upper respiratory or gastrointestinal tract. Ultrasound studies have shown that a (slight) effusion spontaneous limp. The children with transient synovitis is also present, without producing symptoms, in the other are always healthy and are not feverish, nor do they have hip in around a quarter of cases. Confusion There has been much discussion as to whether Legg- can be caused by cases that are superimposed by a current Calvé-Perthes disease can develop from transient sy- viral infection with subfebrile temperatures (e. This idea was postulated in the 1980’s, but has upper respiratory tract. While Legg-Calvé-Perthes disease may be ac- persist or recur without treatment or after the discontinu- companied by an effusion, the underlying disease itself ation of anti-inflammatory measures for periods exceed- can already be diagnosed at this stage sonographically ing two weeks. But even these children are invariably (on the basis of cartilage thickening) and radiologically in good health with no clinical signs of a serious illness. The effusion is never the cause but, at most, distinct limp and significant restriction of hip mobility, a concomitant symptom of the Legg-Calvé-Perthes initially in terms of flexion/extension, subsequently ex- disease. The limp usually occurs spontaneously, sient synovitis, Legg-Calvé-Perthes disease did not subse- although transient episodes of limping during the 10 days quently occur in a single case.

The x-ray shows thick- Haglund’s deformity is a spur-like projection of the ening of the cortical bone and possibly central osteolysis bone over the attachment of the Achilles tendon generic vantin 200mg visa antibiotics for acne vibramycin. The fracture itself is not always visible and buy generic vantin 100 mg line bacteria webquest, if so, extremely rare in adolescents. A more common condi- rarely as a typical as a fracture gap, but rather as a more tion is posterolateral exostosis, in which the bone projects or less diffuse osteolysis resulting from repair processes. A laterally over the calcaneus slightly in front of the Achilles bone scan shows strong uptake. Rather than a genuine exostosis, this The most important differential diagnosis is an os- is more of an anatomical variant, although it can lead teoid osteoma ( Chapter 3. Widening volves cortical thickening and increased uptake on the the footwear is much more useful than surgical chisel- bone scan. Moreover, the osteolysis of the stress fracture ing, since the subsequent scar is more irritating than the can easily be misinterpreted as a nidus of an osteoid former »exostosis«. The most important distinguishing feature is part of the heel, then an insertion tendinosis of the plantar the fact that the pain in a stress fracture is load-related, 428 3. Brunner best way to achieve this is by fitting a below-knee cast, which immobilizes the fracture and effectively stops the The foot represents the lever arm over which the triceps patient from practicing sport. This biome- 3 after 4 weeks, by which time the fatigue fracture has chanical system is primarily responsible for controlling usually healed. In a patient with foot pain one should always think extend (»plantar flexion – knee extension couple«). Tumors are described preconditions for the efficacy of this process: in chapter 3. Bachmann G, Jurgensen I, Rominger M, Rau W (1999) Die Bedeu- (spasticity). Rofo Fortschr Geb Röntgenstr Neuen Bildgeb Verfahr 171: 372–9 Functional or structural foot deformities are very com- 2. Bohndorf K, Imhof H, Schibany N (2001) Bildgebende Diagnostik mon in neurogenic disorders, and can produce widely akuter und chronischer osteochondraler Lasionen am Talus. It is particularly important to thopäde 30: 12–9 distinguish between functionally relevant and cosmetic 3. Borges J, Guille J, Bowen J (1995) Kohler‘s bone disease of the tarsal navicular. Chao K, Lee C, Lin L (1999) Surgery for symptomatic Freiberg‘s also be differentiated from functionally useful ones so that disease: extraarticular dorsal closing-wedge osteotomy in 13 pa- the treatment can be matched to the individual patient’s tients followed for 2–4 years. A tional improvement is required for standing or walking, typical injury. Groß A, Agnidis Z, Hutchison C (2001) Osteochondral defects of or whether the patient is prepared to wear braces such as the talus treated with fresh osteochondral allograft transplanta- inserts or orthoses. Foot Ankle Int 22: 385–91 A common component in neurogenic foot deformi- 7. Hangody L, Kish G, Modis L, Szerb I, Gaspar L, Dioszegi Z, Kendik ties is a functional or structural equinus foot. In a barefoot Z (2001) Mosaicplasty for the treatment of osteochondritis dis- child with an equinus deformity, the weight-bearing area is secans of the talus: two to seven year results in 36 patients. Foot Ankle Int 22: p552–8 small, which makes it more difficult to maintain an upright 8. Higuera J, Laguna R, Peral M, Aranda E, Soleto J (1998) Osteochon- posture. In most cases, stabilizing aids such as inserts or or- dritis dissecans of the talus during childhood and adolescence. J thoses are required in any case to control other components Pediatr Orthop 18: 328–32 of the foot deformities. Ippolito E, Ricciardi Pollini PT, Falez F (1984) Kohler‘s disease of the through corresponding bedding, help improve dynamic tarsal navicular: long-term follow-up of 12 cases. Köhler A (1913) Das Köhlersche Knochenbild des Os naviculare considerations, the equinus foot position is not usually of pedis bei Kindern-keine Fraktur.